Post on 03-Jan-2016
Oxygenation
Ms.Nirmala Priyadarshanie
B.Sc. Nursing (Hons)
Learning Objectives
• Student will be able to :– Identify Anatomy of the Respiratory System– Describe Respiratory Physiology– Identify Respiratory Pathophysiology– Describe Factors Affecting Oxygenation– Identify Alterations in Cardiac Functioning– Describe Respiratory Assessment– Identify Focused History and Physical Examination– Obtain Nursing History– Formulate Nursing Diagnoses– Describe Initial Management
– Respiratory System Anatomy– Respiratory Physiology– Respiratory System Purpose– Respiratory Pathophysiology– Factors Affecting Oxygenation– Alterations in Cardiac Functioning– Respiratory Assessment– Focused History and Physical Examination– Nursing History– Nursing Diagnoses– Initial Management
Out Line
Cardiovascular Physiology
• Structure and function– Myocardial pump– Myocardial blood flow– Coronary artery circulation– Systemic circulation– Blood flow regulation: cardiac output,
preload, afterload, contractility– Conduction system
Upper Respiratory System
Lower Respiratory System
Respiratory System Anatomy
• Lung– Right lung 3 lobes
– Left lung 2 lobes
Respiratory System Anatomy
• Bronchioles– Smallest airways
– Walls consist entirely of smooth muscle (no cartilage present)
– Constriction increases resistance to airflow
– Dilation reduces resistance to airflow
Respiratory System Anatomy
• Alveoli– Air sacs
– Site of oxygen and carbon dioxide exchange with blood
Respiratory System Anatomy
Respiratory System Anatomy
• Diaphragm
Respiratory System Anatomy
• Pleura– Double-walled
membrane
– Visceral layer covers lung
– Parietal layer lines inside of chest wall, diaphragm
Respiratory Physiology
• Structure and function (cont'd)– Breathing: inspiration, expiration– Lung volumes and capacities– Pulmonary circulation– Respiratory gas exchange: oxygen,
carbon dioxide– Regulation of respiration
Respiratory System Purpose
• Takes in oxygen
• Disposes of wastes– Carbon dioxide– Excess water
O2 + Glucose
CO2 + H2O
The Cell
Functions of the Respiratory System
A. Primary functions -1. The respiratory system provides oxygen for metabolism in the tissues.2. The respiratory system removes carbon dioxide, the waste product of metabolism.
B. Secondary functions -1. The respiratory system facilitates sense of smell.2. The respiratory system produces speech.3. The respiratory system maintains acid-base balance.
Physiology
• When you inhale, air enters through the nose or mouth. As air is breathed through the nose, it is warmed, moistened and filtered by the hairs that line the nostrils. The air then passes into the nasal passages. Air from the nasal passages and mouth enters the pharynx and passes downward to the larynx.
Respiratory System Physiology
Inspiration• Active process• Chest cavity expands• Intrathoracic pressure falls
• Air flows in until pressure equalizes
Expiration• Passive process• Chest cavity size decreases• Intrathoracic pressure rises
• Air flows out until pressure equalizes
Respiratory System Physiology
–Automatic Function• Primary drive: increase in arterial CO2
• Secondary (hypoxic) drive: decrease in arterial O2
Normally we breathe to remove CO2 from the body, NOT to get oxygen in
Respiratory Pathophysiology
• Airway (Obstruction)– Tongue
– Foreign body airway obstruction
– Anaphylaxis/angioedema
– Upper airway burn
– Maxillofacial/laryngeal/ tracheobronchial trauma
– Epiglottitis
– Aspiration
– Asthma
– Chronic Obstructive Airway Disease
• Emphysema
• Chronic bronchitis
Respiratory Pathophysiology
• Gas Exchange Surface (Blood Flow or Gas Diffusion)– Pulmonary Edema
• Left-sided heart failure
• Toxic inhalations
• Near drowning
– Pneumonia
– Pulmonary Embolism• Blood clots
• Amniotic fluid
• Fat embolism
Respiratory Pathophysiology
• Thoracic Bellows (Ventilation)– Chest Trauma
• Simple rib fractures
• Pneumothorax
• Hemothorax
• Sucking chest wound
• Diaphragmatic hernia
– Pleural effusion
– Spinal cord trauma (High C-spine lesion)
– Neurological/neuro-muscular disease
• Poliomyelitis
• Myasthenia gravis
• Muscular dystrophy
• Guillian-Barre syndrome
Respiratory Pathophysiology
• Control System (Decreased Respiratory Drive)– Head trauma– CVA– Depressant drug toxicity
• Narcotics
• Sedative-hypnotics
• Ethyl alcohol
Factors Affecting Oxygenation
• Physiological factors: cardiac– Conduction disturbances– Impaired valvular function– Myocardial hypoxia– Cardiomyopathic conditions– Peripheral tissue hypoxia
Factors Affecting Oxygenation (cont'd)
• Physiological factors: respiratory– Hyperventilation– Hypoventilation– Hypoxia
Factors Affecting Oxygenation (cont'd)
• Additional physiological factors– Decreased oxygen-carrying capacity– Decreased inspired oxygen
concentration– Hypovolemia– Increased metabolic rate– Conditions affecting chest wall
movement
Factors Affecting Oxygenation (cont'd)
• Additional physiological factors– Musculoskeletal abnormalities– Trauma– Neuromuscular diseases– Central nervous system alterations– Chronic disease
Alterations in Cardiac Functioning
• Conduction disturbances– Atrial and ventricular dysrhythmias
• Altered cardiac output– Heart failure
• Impaired valvular function
• Myocardial ischemia– Angina, MI, acute coronary
syndrome
Alterations in Respiratory Functioning
• Hyperventilation
• Hypoventilation
• Hypoxia
Developmental Factors
• Infants and toddlers
• School-age children and adolescents
• Young and middle adults
• Older adults
.
Lifestyle Factors
• Nutrition
• Exercise
• Smoking
• Substance abuse
• Stress
Environmental Factors
• Residence location
• Occupation
Respiratory Assessment
• Initial Assessment (A, B, C, D)
• Manage life threats
• Complete focused history and physical
Initial Assessment
• Airway– Listen to patient breathe, talk
• Noisy breathing is obstructed breathing
• But all obstructed breathing is not noisy
• Snoring = Tongue blocking airway
• Stridor = “Tight” upper airway from partial obstruction
Initial Assessment
• Airway
– Anticipate airway problems with• Decreased LOC
• Head trauma
• Maxillofacial trauma
• Neck trauma
• Chest trauma
OPEN—CLEAR—MAINTAIN
Initial Assessment
• Breathing– Is patient moving air?
– Is air moving adequately?
– Is the patient’s blood being oxygenated?
Initial Assessment
• Breathing– LOOK
• Symmetry of chest expansion
• Increased respiratory effort
• Changes in skin color
– LISTEN• Air movement at
mouth, nose• Air Movement in
peripheral lung fields
– FEEL• Air movement at
mouth, nose• Symmetry of chest
expansion
– RATE• Tachypnea• Bradypnea
– POSITIONING• Orthopnea• Tripod position
Initial Assessment
• Breathing– Signs of respiratory distress
• Nasal flaring• Tracheal tugging• Retractions• Neck, pectoral muscle use on inhalation• Abdominal muscle use on exhalation
– Skin Color• Pale, cool moist skin (Early sign of hypoxia)• Cyanosis (Late, unreliable sign of hypoxia)
Initial Assessment
• Breathing– If trauma patient has compromised breathing,
bare chest, assess for:• Open pneumothorax
• Flail chest
• Tension pneumothorax
Respiratory Assessment
• Circulation– Is heart beating?– Is there major external hemorrhage?– Is patient perfusing?– Effects of hypoxia:
• Adults (early): tachycardia
• Adults (late): bradycardia
• Children: bradycardia
Initial Assessment
• Circulation– Don’t let respiratory failure distract you from
assessing for circulatory failure– Low oxygen or high carbon dioxide levels can
depress cardiovascular function
Respiratory Assessment
• Disability– Restlessness, anxiety, combativeness = hypoxia
Until proven otherwise– Drowsiness, lethargy = hypercarbia
Until proven otherwise
Just because the patient stops fighting, he’s not necessarily getting better!!!
Focused History and Physical Examination
• Chief Complaint– Dyspnea
• Subjective sensation that breathing is excessive, difficult, or uncomfortable
– Respiratory Distress• Objective observations that indicate breathing is
difficult or inadequate
Focused History and Physical Examination
• History of Present Illness (OPQRST)– Gradual or sudden onset?
– What aggravates or alleviates?
– How long has dyspnea been present?
– Coughing? Productive cough?
– What does sputum look/smell like?
– Pain present? What does pain feel like? How bad? Does it radiate? Where?
Focused History and Physical Examination
• Past HistoryIf Then???Hypertension, MI, Diabetes CHF with Pulmonary Edema
Chronic Cough , Smoking, COPD
“Recurrent” Flu
Allergies, Acute Episodes of SOB Asthma
Lower Extremity Trauma, Pulmonary Embolism
Recent Surgery, Immobilization
Focused History and Physical Examination
• Medications If Then???“Breathing” Pills, Inhalers Asthma or COPD
Aminophylline
Ipratropium
Terbutaline
Salbumatol
Focused History and Physical Examination
• Medications If Then???
Lasix, hydrodiuril, digitalis CHF
Coumadin Pulmonary embolism
Focused History and Physical Examination
• Crackles (Rales)– Fine, “crackling”
– Fluid in smaller airways, alveoli
• Rhonchi– Coarse, “rumbling”
– Fluid, mucus in larger airways
• Stridor– High pitched, “crowing”– Upper airway restriction
• Wheezing– “Whistling”– Usually more pronounced on
exhalation– Generalized: narrowing,
spasm of the smaller airways– Localized: foreign body
aspiration
Nursing History
• Fatigue
• Dyspnea
• Cough
• Wheezing
• Pain
• Environmental or geographical exposures
Nursing History (cont'd)
• Respiratory infections
• Health risks
• Medications
Assessment of Oxygenation
• Physical examination– Inspection– Palpation– Percussion– Auscultation
Assessment of Oxygenation (cont'd)
• Diagnostic tests: blood studies– Complete blood count– Cardiac enzymes– Cardiac troponin I– Serum electrolytes– Cholesterol
Assessment of Oxygenation (cont'd)
• Diagnostic tests: cardiac function– Electrocardiogram (ECG)– Exercise stress test– Electrophysiological study (EPS)– Echocardiography– Cardiac catheterization
Assessment of Oxygenation (cont'd)
• Diagnostic tests: ventilation studies– Pulmonary function– Peak expiratory flow rate (PEFR)– Arterial blood gases– Oximetry– Chest x-ray– Bronchoscopy– Lung scan
Assessment of Oxygenation (cont'd)
• Diagnostic tests: ventilation studies (cont'd)– Thoracentesis– Throat cultures– Sputum specimens
.
Nursing Diagnoses
• Ineffective airway clearance
• Ineffective breathing pattern
• Decreased cardiac output
• Impaired gas exchange
• Risk for infection
• Ineffective tissue perfusion
• Impaired spontaneous ventilation
.
Planning
• Goals and outcomes– Client’s lungs are clear on auscultation– Client coughs productively
• Setting priorities
• Continuity of care
.
Implementation: Health Promotion
• Body weight• Diet• Exercise• Stress reduction• Occupational safety• Smoke-free• Regular physical examinations
Implementation: Health Promotion (cont'd)
• Vaccinations/immunizations– Influenza– Pneumonia
Implementation: Acute Care
• Dyspnea management
• Airway maintenance– Mobilization of secretions– Suctioning– Artificial airways
Implementation: Acute Care (cont'd)
• Maintenance and promotion of lung expansion– Positioning– Incentive spirometry– Chest tubes
Implementation: Acute Care (cont'd)
• Maintenance and promotion of oxygenation: oxygen therapy– Safety precautions– Oxygen supply– Methods of oxygen delivery– Home oxygen therapy
Implementation: Acute Care (cont'd)
• Restoration of cardiopulmonary functioning—CPR
Initial Management
• Patient Responsive/Breathing Adequate– Oxygen may be indicated– Oxygenate immediately if patient has:
• Decreased level of consciousness• Possible shock• Possible severe hemorrhage• Chest pain• Chest trauma• Respiratory distress or dyspnea• History of any kind of hypoxia
Initial Management
• Patient responsive, breathing inadequate– Open/maintain airway– Place nasopharyngeal airway– Assist ventilations
• Mouth to Mask
• 2-person Bag-valve Mask
• Manually Triggered Ventilator
• 1-person Bag-valve Mask
Initial Management
• Patient unresponsive, breathing adequate– Open/maintain airway– Place nasopharyngeal or oropharyngeal airway– Suction airway as needed– Provide oxygen by non-rebreather mask– Frequently reassess
Initial Management
• Patient unresponsive, breathing inadequate• Open/maintain airway• Place nasopharyngeal or oropharyngeal airway• Suction airway as needed• Assist ventilations
– Mouth to Mask
– 2-person Bag-valve Mask
– Manually Triggered Ventilator
– 1-person Bag-valve Mask
• Frequently reassess
Initial Management
• Patient not breathing– Open airway– Place nasopharyngeal or oropharyngeal airway– Ventilate patient
• Mouth-to-Mask
• 2-Person Bag-Valve Mask
• Manually Triggered Ventilator
• 1-Person Bag-Valve Mask
– Frequently reassess
Initial Management
• Golden Rules– If you think about giving O2, give it!!!
– If you decide to give oxygen, give a lot of it!!!– If you can’t tell whether a patient is breathing
adequately, he isn’t !– If you’re thinking about assisting a patient’s
breathing, you probably should be!
Implementation: Restorative Care
• Hydration
• Coughing techniques
• Respiratory muscle training
• Breathing exercises
Evaluation
• Client care
• Client expectations
Summery……..!
Questions??